International Travel Advice Diagnosis

  • Diagnosis

    Traveling abroad can increase your exposure to infectious diseases. Your risk for acquiring an infectious disease is particularly high if you are traveling to an underdeveloped country that may not have modern water or sewage systems, or if you are going into an area where outbreaks of infectious diseases are known to occur.

    People traveling in underdeveloped tropical and subtropical countries are especially at risk for developing an illness. Studies show that 50% to 75% of travelers in these regions develop some type of health problem. Most of these problems are minor, however, with only about 5% requiring medical attention, and fewer than 1% requiring hospitalization.

    The most significant infectious health hazards for Americans traveling abroad are traveler's diarrhea, malaria, hepatitis A, and typhoid fever. While the Centers for Disease Control and Prevention list 43 infectious diseases of concern to travelers, it is important to remember that infectious illnesses are responsible for only about 1% of deaths among American travelers. Most Americans who die while abroad succumb to heart disease (49%) or injuries (22%).

    Travel-related infectious diseases are caused by viruses, bacteria, or parasites. Some infectious diseases can be transmitted by breathing tiny contaminated droplets from a sneeze or cough, or by touching an infected surface and then touching your nose, eyes, or mouth. Other diseases can be transmitted through sexual contact. Eating food or drinking water contaminated with a germ (pathogen) can also make a traveler ill. Sometimes an insect such as a mosquito, fly, or tick can act as a carrier for pathogens, and can transmit disease with a bite.

    Most cases of traveler's diarrhea are caused by bacteria. Escherichia coliis the bacterium that most commonly causes traveler's diarrhea, but viruses and parasites can also trigger the illness. Traveler's diarrhea is most commonly contracted by ingesting contaminated food or drink.

    Though this is the same bacteria that has caused severe food outbreaks in the U.S. in recent years, it may be a milder strain, and is unlikely to cause life-threatening diarrhea.

    Malaria is caused by amoeba-like parasites that live and multiply within red blood cells. Four species of malaria parasites can infect humans and cause malaria—Plasmodium falciparum,P. malariae, P. vivax,and P. ovale. Malaria caused by P. falciparum is the most serious form; it can lead to life-threatening complications, including kidney failure and coma. Malaria parasites are injected into humans by the Anopheles mosquito, often at dusk when the insects are feeding.

    The hepatitis A virus causes hepatitis A. Hepatitis A is transmitted when a person puts something in his or her mouth that has been contaminated with stool from someone infected with the virus. Travelers who contract hepatitis A often do so by eating or drinking under poor hygienic conditions.

    Typhoid fever is caused by the bacterium Salmonella typhi. Like hepatitis A, typhoid fever is usually acquired by ingesting fecal-contaminated food and water. Once S. typhi bacteria are ingested, they multiply and spread into the bloodstream.

    The symptoms of travel-related infectious diseases vary widely Table 01.

    Traveler's diarrhea is commonly characterized by diarrhea, abdominal cramping, nausea, and vomiting. Traveler's diarrhea usually lasts from three to seven days, and is rarely life-threatening.

    Malaria is characterized by flulike symptoms that may include fever, chills, muscle aches, headache, and sometimes vomiting, diarrhea, and coughing. The symptoms of malaria usually begin 7 to 21 days after the initial bite by an infected mosquito, although sometimes the illness takes up to several months to develop. The symptoms may be mild at first, but within 24 hours may progress to include violent shaking, rapid breathing, and a fever as high as 107° F (41.7°C). People with severe malaria may develop liver and kidney failure, convulsions, and coma.

    People infected with the hepatitis A virus often have no symptoms. When symptoms of hepatitis A are present, they often resemble the flu—mild fever, fatigue, loss of appetite, muscle aches, nausea, and abdominal pain. Some people also have dark urine and yellowing of the skin and eyes (jaundice). Symptoms usually appear 15 to 50 days after infection, and last less than two months. Few people remain ill for longer than six months.

    Symptoms of typhoid fever may include a sustained fever as high as 104° F (40°C), stomach pains, weakness, headache, and loss of appetite. Typhoid fever is sometimes accompanied by a dry cough and constipation or diarrhea. Some people also develop a rash characterized by flat, rose-colored spots. The symptoms may appear three days to three months after exposure to the S. typhi bacterium.

    Although the symptoms of most infections acquired while traveling appear within weeks, some may not show up until much later. It is important that you report any travel to your physician should you become ill after your return, particularly if you had been traveling in underdeveloped areas of the world. Because some infections can remain in your body for a long time before symptoms emerge, you should see your physician when you return from your trip regardless of whether or not you feel sick.

    Table 1.  Symptoms of Significant Travel-Related Infectious llnesses

    Traveler's diarrhea Malaria Hepatitis A Typhoid fever
    DiarrheaAbdominal crampingNauseaVomiting Fever and chillsMuscle achesHeadacheVomiting and diarrhea (sometimes)Coughing (sometimes)Violent shakingRapid breathingA fever as high as 107? F (41.7?C)Convulsions and coma (people with hepatitis A often have no symptoms)Mild feverFatigueLoss of appetiteMuscle achesNauseaAbdominal painDark urine and jaundice (yellowing of skin) A sustained fever as high as 104? F (40?C)Stomach painsWeaknessHeadacheLoss of appetiteDry cough (sometimes)Constipation or diarrhea (sometimes)A rash of flat, rose-colored spots (sometimes)

    Your risk of developing a travel-related illness depends greatly upon your travel destination. People visiting developing countries are at a greater risk of developing a travel-related illness than those traveling in developed areas of the world. Your risk increases even more if you spend extended periods of time in a developing country visiting small cities or rural areas off the usual tourist routes, or if you have prolonged contact with children. Developing countries tend to have lower standards of sanitation and hygiene, which can spread disease. In addition, the rate of vaccination against infectious diseases is lower in developing countries, which means that more people in those countries, especially children, may be carriers of those diseases.

    Older people, young children, pregnant women, and people with suppressed immune systems (such as those infected with HIV) are more susceptible to developing an infectious disease while traveling overseas.

    Infectious diseases picked up in foreign countries are often difficult to diagnose. Your physician will evaluate your symptoms and ask you where you traveled and what precautionary measures you took during your trip to protect yourself against infectious disease. You may be asked, for example, whether you ate shellfish (which can carry several pathogens) or drank the local water. Your physician may also give you routine screening tests, including a complete blood cell count (CBC), which measures the number and type of white blood cells in the blood, a stool examination to look for pathogens, and a skin test for tuberculosis. If your physician suspects hepatitis A or malaria, he or she will order more specific blood tests for diagnosis.

    If you were on an extended trip to a developing county, you should schedule a post-trip evaluation with your physician soon after your return—even if you have no symptoms of illness. Post-trip medical evaluations are particularly important for returning travelers who are pregnant, or who have a chronic disease or a weakened immune system. They are also especially important if you had close contact with the people there, or if you visited rural, remote regions.

    Seek information and advice before traveling abroad. Ideally, you should seek medical travel advice at least 10 weeks before you begin your trip. Your primary care physician or local public health department should be able to give you advice about which immunizations are required or recommended for the country you are visiting. Some communities also have travel clinics that specialize in giving medical advice, immunizations, and other preventive medications to overseas travelers.

    You can also get information through the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. For information on recommended vaccinations and country-specific health information, contact the CDC's International Travelers' Health Fax Service (404-332-4565). You can request information through this automated system and have it faxed directly to you. Faxed information about individual diseases—such as malaria, cholera and yellow fever—is available through the CDC's toll-free service, (888) 232-3299. You can also use the CDC's Travelers' Health website: www.cdc.gov/travel/.

    Choose and prepare your foods carefully Table 02. Make sure the foods you eat have been thoroughly cooked, and are still hot and steaming when served to you. Be sure to peel all raw vegetables and fruits before eating them, and avoid eating any that cannot be peeled.

    Cooked fish may contain dangerous toxins. The most common type of seafood poisoning is ciguatera poisoning, which is caused by natural toxic substances known as ciguatoxins. These toxins are most commonly found in barracuda, but also from time to time in red snapper, grouper, amberjack, sea bass, and other tropical fish. Some travelers have gotten cholera from crab bought back from Central America. The areas of highest risk for unsafe fish include the islands of the West Indies and the tropical Pacific and Indian Oceans.

    If you eat dairy products on your trip, consume only pasteurized products, as you can get sick from the bacteria in unpasteurized dairy products.

    Make sure that water you drink is purified, boiled, or bottled. Boil water for at least five minutes unless you are certain that it is safe to drink. You can also use a purification filter device. These devices can remove most bacteria and parasites, but not viruses. If you are going to be in an area where the water is heavily contaminated, you may need to treat the filtered water with a purifying chemical: either tincture of iodine or tetraglycine hydroperiodide. These chemicals are sold in tablet form at most sporting goods stores and pharmacies. People with thyroid disease or an iodine allergy, however, should avoid the tincture of iodine method of purification.

    When ordering beverages, ask for drinks without ice unless the ice is made from bottled or boiled water. Additionally, you should not use tap water for brushing your teeth.

    Use a condom with every sexual encounter. If you have sex with local people while traveling, remember that safer sex is particularly important in countries where there is limited public health awareness, or few or ineffective public health initiatives. For example, it would be particularly risky to engage in unprotected sex in a country such as Africa, where there is an AIDS epidemic.

    Travelers should bring condoms with them on overseas trips. Condoms bought overseas—particularly in developing countries—may not be as reliable as those available in the U.S.

    Stay away from animals, which may be carriers of rabies. While traveling, avoid all wild animals, and be cautious around pets as well—particularly ones that appear ill. Seek medical care immediately if you are bitten.

    Protect yourself against insect bites. Protecting yourself against insect bites can also help to lower your risk of acquiring a travel-related illness. To avoid mosquitoes, ticks, fleas, and other biting insects that can carry diseases, apply insect repellent to exposed skin and on clothing. A repellent containing 20% to 30% DEET (diethyl toluamide) is recommended. Apply the repellant sparingly, and wash it off with soap and water when it is no longer needed. DEET can be absorbed through the skin, and at higher concentrations may cause such side effects as skin rash, insomnia, irritability, and seizures. Children, pregnant women, and people with skin conditions should be particularly careful when using DEET. In addition, wearing long-sleeved clothing and long pants when outdoors at night can also help prevent insect bites. Spraying your clothing with a permethrin-containing insecticide can create a shield against insects. The spray usually lasts through several clothes washings. You can also sleep with a permethrin-treated mosquito net over your bed if your bedroom is not air-conditioned or screened.

    Get the recommended immunizations before you travel Table 03. Some travel-related infectious diseases can be prevented with immunizations. It's important to plan far in advance—at least 10 weeks, preferably—for these vaccines. Although most of the vaccines can be given together, some require more than one dose. Others, such as those against hepatitis A and yellow fever, become effective a week or more after the immunization has been given.

    • Yellow fever: Certain countries require travelers crossing their borders to provide a signed certificate proving they have been vaccinated against yellow fever. Some countries require all travelers to show proof of vaccination, while others require it only of travelers coming from either areas where yellow fever is known to exist, or areas where yellow fever transmission has occurred (called “endemic” areas). The endemic areas are found in tropical South America and Africa. For the current list of “infected” or endemic countries and a list of countries that require proof of vaccination, contact the CDC.

      Because the yellow fever vaccine is very perishable, only certain health facilities that agree to stringent conditions regarding its transportation, handling, storage, and administration are authorized to validate the international certificate of vaccination. For the location of designated Yellow Fever Vaccination Centers near you, contact your local health department.

      The yellow fever vaccine available in the United States is highly effective against both jungle and urban forms of the disease, and provides long-lasting immunity (at least 10 years). The vaccine has a very good safety record, and causes mild symptoms like muscular pain, headache, or low-grade fever in 2% to 5% of people receiving the vaccine. Serious complications such as encephalitis are exceedingly rare, and occur almost exclusively in children under six months of age.

    • Diphtheria/tetanus: You should have been immunized against these diseases during childhood, and should have had a booster vaccine within the past 10 years. If not, make sure you are up-to-date on these immunizations before traveling. The booster is especially important for people traveling to areas of the former Soviet Union that have experienced recent outbreaks of diphtheria.
    • Polio: All adults should be immunized. Persons with no or unknown prior immunization should complete a three-dose schedule of the inactivated polio vaccine (IPV) before traveling abroad. The live oral polio vaccine (OPV) is recommended only in situations of immediate high-risk exposure. Transmission of the polio virus still occurs in many developing countries of Africa, Asia, the Middle East, and eastern Europe. Travelers to these countries should be fully immunized. There is no risk of polio virus infection in any country of the western hemisphere.
    • Measles: All adults should be immunized unless they were born before 1957 (and probably had the disease), were immunized for measles after 1979, or have a history of physician-diagnosed measles. Make sure you are up-to-date on this vaccine before traveling. Measles is endemic in most parts of the developing world.
    • Chickenpox: Although there is no formal recommendation that travelers be vaccinated against chickenpox, people susceptible to the illness may benefit from having the vaccine. Unless you definitely have had chickenpox or shingles, talk with your physician to determine if you need a chickenpox vaccination before traveling.
    • Flu and pneumonia: It is wise to be vaccinated against the flu (influenza) before traveling; particularly if you will be traveling during flu season. Travelers who are at high risk of developing pneumonia (such as the elderly and people with suppressed immune systems) should make sure they also receive the pneumococcal vaccine.
    • Typhoid: The typhoid vaccine is recommended for people traveling to remote and underdeveloped areas, and to areas that have recently had typhoid epidemics. Persons who have inadequate stomach acid (achlorhydria) or are taking medications that block acid secretion have an increased risk of typhoid infection. Two vaccines are currently used to prevent typhoid. The oral typhoid vaccine Ty21 consists of four capsules taken orally over a two-week period. Children must be at least six years old to receive this vaccine, and reimmunization is required every five years. The ViCPS typhoid vaccine consists of a single injection. Children must be at least two years old to get this vaccine, and re-immunization is required every two years. Typhoid is prevalent in most countries of Latin America, Africa, and Asia. The vaccines are effective in preventing the disease in up to 70% of cases.
    • Hepatitis A: If you are traveling to areas with uncertain sanitary conditions, you may benefit from having the hepatitis A vaccine. Two hepatitis A vaccines are licensed for use in the United States: Havrix and Vaqta. Both are injected into the muscle, and take four weeks to become effective. For children under two years of age, immunization with immune globulin is recommended.
    • Hepatitis B: Hepatitis B is very common in many developing countries. Your risk of developing the illness, however, depends largely on your activities in those countries. Travelers at greatest risk are those who have sexual contact with commercial sex workers, or those who have direct contact with blood or other secretions (such as health care workers). Travelers who fall into either of these categories should be vaccinated against hepatitis B. People who will be living for a prolonged time in an area where hepatitis B is prevalent should also be vaccinated against hepatitis B, as they may need to use local dental or medical facilities, thus increasing their risk of developing the illness.
    • Rabies: If you are going to be spending a prolonged time in areas where rabies is endemic (Africa, the Middle East, and Asia), then you should consider having a rabies vaccine. Getting the vaccine does not eliminate the need for treatment after exposure to the rabies virus. The rabies vaccine is given in three intramuscular injections over a three- to four-week period. Because medications that are given to prevent malaria can interfere with the body's immune response to rabies vaccine, you should complete the three-dose rabies series before beginning malarial prophylaxis.
    • Japanese encephalitis: Outbreaks of this mosquito-borne disease can occur during the late summer and early autumn in parts of Asia and the Far East. If you are planning prolonged travel (more than a month) to these areas—especially trips into rural farming areas—then you should consider getting vaccinated against the disease. The vaccine is given in three doses over a period of one month, and becomes effective 10 days after the final dose.
    • Meningitis: Outbreaks of this bacterial disease occur frequently in sub-Saharan Africa during the dry season (December through June)—particularly in the savannah areas extending from Mali eastward to Ethiopia. If you will be traveling to these areas during the dry season, you should receive the meningococcal vaccine; especially if you will be in prolonged contact with local people. Saudi Arabia requires that all pilgrims to Mecca for the annual Hajj be vaccinated against meningitis.

    Table 2.  Preventive Health Tips for Travelers

    Have a medical and dental checkup before you leave for your trip
    Make sure you are up-to-date on all standard immunizations
    Seek advice from your physician or a travel clinic about other recommended vaccinations and preventive medications
    Avoid insect bites
    Keep your shoes on when outside
    Follow precautions when choosing foods and drinking water
    Stay away from animals, and seek medical care immediately if bitten
    Practice safe sex?always use a condom
    Have a medical checkup when you return from your trip if you became ill while away or if you are having symptoms now

    Table 3.  Immunizations for Travelers

    Immunizations required by certain countries
    Yellow fever
    Vaccine updates for standard immunizations
    Diphtheria/tetanusPolioMeaslesChickenpoxFlu and pneumonia
    Immunization for travelers to areas with poor sanitation and uncertain water purity
    TyphoidHepatitis A
    Immunizations indicated in special circumstances
    Hepatitis BRabiesJapanese encephalitisMeningitis

    Take antimalarial medications if recommended by your physician Preventive medications can be taken before, during, and after a trip for protection against malaria. Chloroquine is the prophylactic medicine most often prescribed for travelers who will be spending time in areas where malaria is endemic. You should begin taking the drug one to two weeks before entering a malarious area, and continue taking it for four weeks after leaving the area. In some parts of the world, chloroquine-resistant forms of malaria have developed. If you are going to these areas, you may be given the drugs mefloquine or doxycycline.

    Take a traveler's medical kit with you on your trip Table 04. Depending on where you are going, how long you are staying, what the living conditions will be at your destination, and whether you will have easy access to medical facilities during your stay, you may want to take a medical kit with you on your travels. If you are going to be in remote areas where adequate medical care is likely to be unavailable, ask you doctor about whether some prescription medications should be included in your medical kit.

    Table 4.  Items in a Medical Kit

    Adhesive bandages, sterile gauze pads (2 ? 2 inches) adhesive tape, scissors, knife (a Swiss army-type with blade, scissors, and tweezers is especially useful)
    Elastic bandage wrap
    Bactericidal soap solution
    Alcohol wipes
    Thermometer
    Pocket flashlight
    Sunscreen
    Insect repellent spray and lotion
    Water purification tablets
    Over-the-counter items
    Acetaminophen
    Hydrocortisone cream (0.5%)
    Antidiarrhea medication (Imodium)
    Topical solution for athlete's foot
    Nasal decongestant

    Have a medical checkup when you return from your trip. If you have traveled to high-risk (underdeveloped, remote) areas or engaged in high-risk activities (close contact with the local population in rural areas), you should get a medical checkup upon your return regardless of whether or not you became ill during your trip or after your return. Some infectious diseases take a long time to cause symptoms. Therefore, even if you feel well, you may have picked up an illness of which you are not yet aware.

  • Prevention and Screening

    Seek information and advice before traveling abroad. Ideally, you should seek medical travel advice at least 10 weeks before you begin your trip. Your primary care physician or local public health department should be able to give you advice about which immunizations are required or recommended for the country you are visiting. Some communities also have travel clinics that specialize in giving medical advice, immunizations, and other preventive medications to overseas travelers.

    You can also get information through the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. For information on recommended vaccinations and country-specific health information, contact the CDC's International Travelers' Health Fax Service (404-332-4565). You can request information through this automated system and have it faxed directly to you. Faxed information about individual diseases—such as malaria, cholera and yellow fever—is available through the CDC's toll-free service, (888) 232-3299. You can also use the CDC's Travelers' Health website: www.cdc.gov/travel/.

    Choose and prepare your foods carefully Table 02. Make sure the foods you eat have been thoroughly cooked, and are still hot and steaming when served to you. Be sure to peel all raw vegetables and fruits before eating them, and avoid eating any that cannot be peeled.

    Cooked fish may contain dangerous toxins. The most common type of seafood poisoning is ciguatera poisoning, which is caused by natural toxic substances known as ciguatoxins. These toxins are most commonly found in barracuda, but also from time to time in red snapper, grouper, amberjack, sea bass, and other tropical fish. Some travelers have gotten cholera from crab bought back from Central America. The areas of highest risk for unsafe fish include the islands of the West Indies and the tropical Pacific and Indian Oceans.

    If you eat dairy products on your trip, consume only pasteurized products, as you can get sick from the bacteria in unpasteurized dairy products.

    Make sure that water you drink is purified, boiled, or bottled. Boil water for at least five minutes unless you are certain that it is safe to drink. You can also use a purification filter device. These devices can remove most bacteria and parasites, but not viruses. If you are going to be in an area where the water is heavily contaminated, you may need to treat the filtered water with a purifying chemical: either tincture of iodine or tetraglycine hydroperiodide. These chemicals are sold in tablet form at most sporting goods stores and pharmacies. People with thyroid disease or an iodine allergy, however, should avoid the tincture of iodine method of purification.

    When ordering beverages, ask for drinks without ice unless the ice is made from bottled or boiled water. Additionally, you should not use tap water for brushing your teeth.

    Use a condom with every sexual encounter. If you have sex with local people while traveling, remember that safer sex is particularly important in countries where there is limited public health awareness, or few or ineffective public health initiatives. For example, it would be particularly risky to engage in unprotected sex in a country such as Africa, where there is an AIDS epidemic.

    Travelers should bring condoms with them on overseas trips. Condoms bought overseas—particularly in developing countries—may not be as reliable as those available in the U.S.

    Stay away from animals, which may be carriers of rabies. While traveling, avoid all wild animals, and be cautious around pets as well—particularly ones that appear ill. Seek medical care immediately if you are bitten.

    Protect yourself against insect bites. Protecting yourself against insect bites can also help to lower your risk of acquiring a travel-related illness. To avoid mosquitoes, ticks, fleas, and other biting insects that can carry diseases, apply insect repellent to exposed skin and on clothing. A repellent containing 20% to 30% DEET (diethyl toluamide) is recommended. Apply the repellant sparingly, and wash it off with soap and water when it is no longer needed. DEET can be absorbed through the skin, and at higher concentrations may cause such side effects as skin rash, insomnia, irritability, and seizures. Children, pregnant women, and people with skin conditions should be particularly careful when using DEET. In addition, wearing long-sleeved clothing and long pants when outdoors at night can also help prevent insect bites. Spraying your clothing with a permethrin-containing insecticide can create a shield against insects. The spray usually lasts through several clothes washings. You can also sleep with a permethrin-treated mosquito net over your bed if your bedroom is not air-conditioned or screened.

    Get the recommended immunizations before you travel Table 03. Some travel-related infectious diseases can be prevented with immunizations. It's important to plan far in advance—at least 10 weeks, preferably—for these vaccines. Although most of the vaccines can be given together, some require more than one dose. Others, such as those against hepatitis A and yellow fever, become effective a week or more after the immunization has been given.

    • Yellow fever: Certain countries require travelers crossing their borders to provide a signed certificate proving they have been vaccinated against yellow fever. Some countries require all travelers to show proof of vaccination, while others require it only of travelers coming from either areas where yellow fever is known to exist, or areas where yellow fever transmission has occurred (called “endemic” areas). The endemic areas are found in tropical South America and Africa. For the current list of “infected” or endemic countries and a list of countries that require proof of vaccination, contact the CDC.

      Because the yellow fever vaccine is very perishable, only certain health facilities that agree to stringent conditions regarding its transportation, handling, storage, and administration are authorized to validate the international certificate of vaccination. For the location of designated Yellow Fever Vaccination Centers near you, contact your local health department.

      The yellow fever vaccine available in the United States is highly effective against both jungle and urban forms of the disease, and provides long-lasting immunity (at least 10 years). The vaccine has a very good safety record, and causes mild symptoms like muscular pain, headache, or low-grade fever in 2% to 5% of people receiving the vaccine. Serious complications such as encephalitis are exceedingly rare, and occur almost exclusively in children under six months of age.

    • Diphtheria/tetanus: You should have been immunized against these diseases during childhood, and should have had a booster vaccine within the past 10 years. If not, make sure you are up-to-date on these immunizations before traveling. The booster is especially important for people traveling to areas of the former Soviet Union that have experienced recent outbreaks of diphtheria.
    • Polio: All adults should be immunized. Persons with no or unknown prior immunization should complete a three-dose schedule of the inactivated polio vaccine (IPV) before traveling abroad. The live oral polio vaccine (OPV) is recommended only in situations of immediate high-risk exposure. Transmission of the polio virus still occurs in many developing countries of Africa, Asia, the Middle East, and eastern Europe. Travelers to these countries should be fully immunized. There is no risk of polio virus infection in any country of the western hemisphere.
    • Measles: All adults should be immunized unless they were born before 1957 (and probably had the disease), were immunized for measles after 1979, or have a history of physician-diagnosed measles. Make sure you are up-to-date on this vaccine before traveling. Measles is endemic in most parts of the developing world.
    • Chickenpox: Although there is no formal recommendation that travelers be vaccinated against chickenpox, people susceptible to the illness may benefit from having the vaccine. Unless you definitely have had chickenpox or shingles, talk with your physician to determine if you need a chickenpox vaccination before traveling.
    • Flu and pneumonia: It is wise to be vaccinated against the flu (influenza) before traveling; particularly if you will be traveling during flu season. Travelers who are at high risk of developing pneumonia (such as the elderly and people with suppressed immune systems) should make sure they also receive the pneumococcal vaccine.
    • Typhoid: The typhoid vaccine is recommended for people traveling to remote and underdeveloped areas, and to areas that have recently had typhoid epidemics. Persons who have inadequate stomach acid (achlorhydria) or are taking medications that block acid secretion have an increased risk of typhoid infection. Two vaccines are currently used to prevent typhoid. The oral typhoid vaccine Ty21 consists of four capsules taken orally over a two-week period. Children must be at least six years old to receive this vaccine, and reimmunization is required every five years. The ViCPS typhoid vaccine consists of a single injection. Children must be at least two years old to get this vaccine, and re-immunization is required every two years. Typhoid is prevalent in most countries of Latin America, Africa, and Asia. The vaccines are effective in preventing the disease in up to 70% of cases.
    • Hepatitis A: If you are traveling to areas with uncertain sanitary conditions, you may benefit from having the hepatitis A vaccine. Two hepatitis A vaccines are licensed for use in the United States: Havrix and Vaqta. Both are injected into the muscle, and take four weeks to become effective. For children under two years of age, immunization with immune globulin is recommended.
    • Hepatitis B: Hepatitis B is very common in many developing countries. Your risk of developing the illness, however, depends largely on your activities in those countries. Travelers at greatest risk are those who have sexual contact with commercial sex workers, or those who have direct contact with blood or other secretions (such as health care workers). Travelers who fall into either of these categories should be vaccinated against hepatitis B. People who will be living for a prolonged time in an area where hepatitis B is prevalent should also be vaccinated against hepatitis B, as they may need to use local dental or medical facilities, thus increasing their risk of developing the illness.
    • Rabies: If you are going to be spending a prolonged time in areas where rabies is endemic (Africa, the Middle East, and Asia), then you should consider having a rabies vaccine. Getting the vaccine does not eliminate the need for treatment after exposure to the rabies virus. The rabies vaccine is given in three intramuscular injections over a three- to four-week period. Because medications that are given to prevent malaria can interfere with the body's immune response to rabies vaccine, you should complete the three-dose rabies series before beginning malarial prophylaxis.
    • Japanese encephalitis: Outbreaks of this mosquito-borne disease can occur during the late summer and early autumn in parts of Asia and the Far East. If you are planning prolonged travel (more than a month) to these areas—especially trips into rural farming areas—then you should consider getting vaccinated against the disease. The vaccine is given in three doses over a period of one month, and becomes effective 10 days after the final dose.
    • Meningitis: Outbreaks of this bacterial disease occur frequently in sub-Saharan Africa during the dry season (December through June)—particularly in the savannah areas extending from Mali eastward to Ethiopia. If you will be traveling to these areas during the dry season, you should receive the meningococcal vaccine; especially if you will be in prolonged contact with local people. Saudi Arabia requires that all pilgrims to Mecca for the annual Hajj be vaccinated against meningitis.

    Table 2.  Preventive Health Tips for Travelers

    Have a medical and dental checkup before you leave for your trip
    Make sure you are up-to-date on all standard immunizations
    Seek advice from your physician or a travel clinic about other recommended vaccinations and preventive medications
    Avoid insect bites
    Keep your shoes on when outside
    Follow precautions when choosing foods and drinking water
    Stay away from animals, and seek medical care immediately if bitten
    Practice safe sex?always use a condom
    Have a medical checkup when you return from your trip if you became ill while away or if you are having symptoms now

    Table 3.  Immunizations for Travelers

    Immunizations required by certain countries
    Yellow fever
    Vaccine updates for standard immunizations
    Diphtheria/tetanusPolioMeaslesChickenpoxFlu and pneumonia
    Immunization for travelers to areas with poor sanitation and uncertain water purity
    TyphoidHepatitis A
    Immunizations indicated in special circumstances
    Hepatitis BRabiesJapanese encephalitisMeningitis

    Take antimalarial medications if recommended by your physician Preventive medications can be taken before, during, and after a trip for protection against malaria. Chloroquine is the prophylactic medicine most often prescribed for travelers who will be spending time in areas where malaria is endemic. You should begin taking the drug one to two weeks before entering a malarious area, and continue taking it for four weeks after leaving the area. In some parts of the world, chloroquine-resistant forms of malaria have developed. If you are going to these areas, you may be given the drugs mefloquine or doxycycline.

    Take a traveler's medical kit with you on your trip Table 04. Depending on where you are going, how long you are staying, what the living conditions will be at your destination, and whether you will have easy access to medical facilities during your stay, you may want to take a medical kit with you on your travels. If you are going to be in remote areas where adequate medical care is likely to be unavailable, ask you doctor about whether some prescription medications should be included in your medical kit.

    Table 4.  Items in a Medical Kit

    Adhesive bandages, sterile gauze pads (2 ? 2 inches) adhesive tape, scissors, knife (a Swiss army-type with blade, scissors, and tweezers is especially useful)
    Elastic bandage wrap
    Bactericidal soap solution
    Alcohol wipes
    Thermometer
    Pocket flashlight
    Sunscreen
    Insect repellent spray and lotion
    Water purification tablets
    Over-the-counter items
    Acetaminophen
    Hydrocortisone cream (0.5%)
    Antidiarrhea medication (Imodium)
    Topical solution for athlete's foot
    Nasal decongestant

    Have a medical checkup when you return from your trip. If you have traveled to high-risk (underdeveloped, remote) areas or engaged in high-risk activities (close contact with the local population in rural areas), you should get a medical checkup upon your return regardless of whether or not you became ill during your trip or after your return. Some infectious diseases take a long time to cause symptoms. Therefore, even if you feel well, you may have picked up an illness of which you are not yet aware.

Recommended Reading

Meet the Pharmacists

I'm Beth Isaac, PharmD. Welcome to PDR Health!

Check out my latest post on cholesterol drugs.

International Travel Advice Related Drugs

International Travel Advice Related Conditions